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Local suffering and the global discourse of mental health and human
rights: An ethnographic study of responses to mental illness in rural
Ghana
Ursula M Read1, Edward Adiibokah*2 and Solomon Nyame2
Address: 1Department of Anthropology, University College London, UK and 2Kintampo Health Research Centre, Kintampo, Brong Ahafo, Ghana
Email: Ursula M Read - u.read@ucl.ac.uk; Edward Adiibokah* - adiiboka@yahoo.com; Solomon Nyame - meronzi12345@yahoo.com
* Corresponding author
doi:10.1186/1744-8603-5-13
Abstract
Background: The Global Movement for Mental Health has brought renewed attention to the
neglect of people with mental illness within health policy worldwide. The maltreatment of the
mentally ill in many low-income countries is widely reported within psychiatric hospitals, informal
healing centres, and family homes. International agencies have called for the development of
legislation and policy to address these abuses. However such initiatives exemplify a top-down
approach to promoting human rights which historically has had limited impact at the level of those
living with mental illness and their families.
Methods: This research forms part of a longitudinal anthropological study of people with severe
mental illness in rural Ghana. Visits were made to over 40 households with a family member with
mental illness, as well as churches, shrines, hospitals and clinics. Ethnographic methods included
observation, conversation, semi-structured interviews and focus group discussions with people
with mental illness, carers, healers, health workers and community members.
Results: Chaining and beating of the mentally ill was found to be commonplace in homes and
treatment centres in the communities studied, as well as with-holding of food ('fasting'). However
responses to mental illness were embedded within spiritual and moral perspectives and such
treatment provoked little sanction at the local level. Families struggled to provide care for severely
mentally ill relatives with very little support from formal health services. Psychiatric services were
difficult to access, particularly in rural communities, and also seen to have limitations in their
effectiveness. Traditional and faith healers remained highly popular despite the routine
maltreatment of the mentally ill in their facilities.
Conclusion: Efforts to promote the human rights of those with mental illness must engage with
the experiences of mental illness within communities affected in order to grasp how these may
underpin the use of practices such as mechanical restraint. Interventions which operate at the local
level with those living with mental illness within rural communities, as well as family members and
healers, may have greater potential to effect change in the treatment of the mentally ill than
legislation or investment in services alone.
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Background
The contribution of mental disorders to the burden of
chronic disease has been re-affirmed in the latest update
to the Global Burden of Disease (GBD) study. This identifies neuropsychiatric conditions including depression,
psychoses and alcohol use disorders, as the leading causes
of disability worldwide, representing a third of all years of
healthy life lost to disability among adults [1]. According
to this study, the burden of disability is highest in African
countries, presumably due to the impact of poverty and
low levels of treatment and rehabilitation for chronic diseases. Within sub-Saharan Africa the majority of those
with mental disorders receive no treatment from mental
health services. In a study in Nigeria, for example, only
9% of 1,682 people diagnosed with anxiety, mood or substance use disorder had received any treatment, and even
this treatment was judged to be inadequate [2]. Mental
health care is underfunded across the continent compared
to other health concerns. According to the World Health
Organization (WHO), 70% of African countries spend
less than 1% of their health budgets on mental health [3].
Even then the majority of government funding for mental
health is consumed in maintaining large psychiatric institutions, with very little allocated for the treatment and
prevention of mental disorders in the community. In
common with general health care and other public services, psychiatric services tend to be concentrated within
the urban centres of most countries of sub-Saharan Africa.
This means that the poorest members of these countries
who live in rural areas far from the capitals and major cities face the greatest challenges in accessing mental health
care.
In response to these deficits in mental healthcare, 2008
witnessed the launch of The Global Movement for Mental
Health http://www.globalmentalhealth.org. The movement has three key objectives: the scaling up of mental
health services, protecting human rights, and promoting
research in low- and middle-income countries. This
movement is the latest development in a global push for
improved mental health care which began in 2001 with
the World Health Report on mental health [4]. It received
renewed impetus in 2007 with the publication of the Lancet series on mental health which highlighted the paucity
of attention to mental health in the global public health
forum culminating in a 'call for action' [5]. This call,
which forms the foundation of the Global Movement for
Mental Health, suggests that Government ministries
should 'identify and scale up a priority package of service
interventions or components that can form the backbone
of a national mental health system that provides effective
interventions and human-rights protection' [5]. Recommended strategies are in line with long-standing recommendations for the delivery of mental health care which
emphasize the need for decentralisation, community-
http://www.globalizationandhealth.com/content/5/1/13
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Methods
Fieldwork setting
The study centres around a rural town, Kintampo, in
Brong Ahafo, in the central belt of Ghana. Kintampo
forms a transit zone between north and south, and is
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camps' established by Christian pastors who provide healing through prayer, fasting and deliverance from evil spirits. One pastor in Kintampo town is well-known in the
area for his power in healing those who are mentally ill,
and hundreds if not thousands of pastors offer similar
services throughout the country. A shrine in a small rural
community in Kintampo South district is also famed for
healing madness and is visited by people from as far afield
as the Ashanti region and sometimes beyond. Treatment
at prayer camps and shrines often involves a lengthy stay
of several months; sometimes up to a year or even more.
Relatives are usually expected to stay with the patient at
the prayer camps and shrines to provide day-to-day care.
Most frequently this is the mother, but sometimes the
father, sister or another relative takes this role.
Research design
Despite longstanding calls for the contribution of anthropology to explore the influence of culture on the experience and outcome of mental illness [18-20], there are few
detailed ethnographic studies of people living with mental illness in low-income countries. Many studies provide
little detail about the socio-cultural world in which people live, and the ways in which people with mental illness
are treated by their families, friends or the general population [18,19,21,22]. This research draws on the methods
of transcultural psychiatry which views mental illness as a
function of 'the unique experience of being a member of
a particular society: a society with its own characteristic
web of economic constraints, social relations and beliefs'
[23]. Utilising anthropological methods including participant observation, conversation and semi-structured
interviews with people with mental illness, their families,
healers, health professionals and community members
within Kintampo town and the surrounding villages, the
study aimed to discover the particularities of responses to
severe mental illness as embedded within the experience
of living in a rural West African community.
Research subjects
Participants were recruited through purposive sampling at
shrines, churches, prayer camps and family homes. Initially the researchers identified one shrine and two prayer
camps within the Kintampo districts who frequently
treated people with mental illness. The shrine regularly
had 8-10 people with mental illness staying in the compound. However the two prayer camps were relatively
small without a frequent turnover of patients, so a larger
prayer camp was identified in Techiman, a market town
thirty minutes from Kintampo, where there were greater
numbers of people with mental illness. All of these healing centres took patients from across the country, though
predominantly from Brong Ahafo and Ashanti regions.
Permission was sought from the pastor or kmfo to
approach potential participants visiting the shrine/
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Kintampo
Sunyani
Kumasi
Greater Accra
Cape Coast
Figure
Map
by
participants
of Ghana
1
showing location of psychiatric facilities used
Map of Ghana showing location of psychiatric facilities used by participants.
church. Other participants were recruited from the database of an earlier epidemiological study of psychosis
http://www.iop.kcl.ac.uk/international/?project_id=54,
patients attending the CPN clinic, and through contacts in
the community (see Table 1).
The focus of the study is on those who in Twi would be
described as bdamfo, or a mad person. This behaviour is
identified by local informants with forms of 'wild' and
anti-social behaviour and is closest to what in psychiatric
terms would be labelled psychosis. Frequently described
behaviours include talking to oneself, talking in a disordered way (kasa basabasa), acting aggressively (gidigidi),
and dressing in dirty clothing. The study focuses on those
with more longstanding forms of mental illness which
involve severe disruption of perception, thought, and
Fieldwork
Anthropological fieldwork requires prolonged immersion
in the community under study and participation in everyday life, typically for a period of at least one year, in order
for the researcher to become familiar with local practices
and to minimise the reactivity of informants [24]. Fieldwork took place between October 2007 and December
2008 following a pilot study in June - July 2006. The principal researcher (UMR) lived within Kintampo during the
period of fieldwork, and spent time informally with people living in the Kintampo districts, observing practices
such child-rearing, food preparation, agricultural practices, social relationships and other daily routines. The
fieldwork assistant (SN) was trained in ethnographic
methods, including participant observation and semistructured interviewing. He accompanied the principal
researcher on visits to field sites, and provided assistance
with interpretation, conducting interviews and focus
groups, and arranging entry to the field. The assistant also
functioned as an 'expert informant' during participant
observation, to assist with the explanation of practices
observed, as well as with interpretation. The research consisted of three main approaches: detailed case studies of
people with mental illness, in-depth observation of treatment and healing practices for mental illness, and gathering contextual information relevant to mental illness (see
Appendix 1).
Alongside interviews to elicit verbal accounts, an important part of the research involved spending time with people with mental illness and their families observing their
everyday life and their integration and participation
within the community, including the attitudes of others
towards them. Regular visits were undertaken to the
homes of families who had a relative with mental illness,
to the shrine, and to the three churches treating people
with mental illness. Fieldnotes were written by the
researcher and the assistant to record observations and
conversations following each visit.
During the course of the research over 40 homes were visited in addition to the shrine and prayer camps, and a
total of 67 participants were interviewed including 25
patients, 31 carers, 3 traditional healers, 4 pastors, 1 mallam and 3 imams (see Table 2). Three interviews were in
English, the rest in Twi. Wherever possible we interviewed
the person with mental illness, however some were too
unwell to provide consent or to participate in the interview, in which case we interviewed the main carer, usually
the mother, father or sibling. In eight of the interviews the
carer and the person with mental illness were interviewed
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together. This was due to the fact that these patients could
not remember significant details of the time when they
were sick, or suffered from deficits in communication or
cognition which made it difficult to obtain a coherent
interview alone. To obtain contextual information relevant to mental health 7 focus group discussions were held
with a total of 47 participants including registered mental
nurses, young people, Muslims, cannabis users, church
members and parents (see Table 3). Five FGDs were conducted in Twi; two in English. Interviews were semi-structured. For those with mental illness and their family
members questions focused on the history of the person's
illness, the symptoms and course of the illness, possible
causes, the impact of the illness on the individual and the
family in terms of day-to-day life and social roles, sources
of treatment employed, and the experience of such treatment, including its perceived efficacy. For healers interview questions focused on the healers' view of mental
illness, including possible causes, the methods of treatment provided and the ideology/theology on which they
were based, the efficacy of the treatment and the reasons
for this, and views of other forms of treatment and possible collaboration or interaction.
Data analysis
Interviews and focus groups were digitally recorded with
the permission of the informants. Five assistants bi-lingual in Twi and English were recruited and trained. They
transcribed the interviews and focus groups into Twi and
then translated into English. All potentially identifying
details were removed in the transcripts. Analysis utilised a
grounded theory approach in which hypotheses were generated through close examination of the data [24]. Transcripts and fieldnotes were read and recurring themes and
differences noted. The multiple methods used allowed for
some triangulation of the data.
Ethics
Ethical approval for the study was granted by University
College London and Kintampo Health Research Centre
(KHRC). On introduction all participants in interviews
and focus groups were provided with a written information sheet and consent form which was translated into
Twi. As many participants were unable to read Twi the
forms were read to the participants and a verbal explanation of the research aims and methods provided. Questions were invited from participants. Participants were
asked to sign consent forms, or if illiterate to provide
thumb prints in the presence of a witness. Where possible
the researchers aimed to interview the person with mental
illness and the main carer. However if the person with
mental illness was considered too unwell to provide
informed consent, he or she was not interviewed.
It is not feasible nor appropriate to obtain written consent
from all persons who may be involved in observation, for
example a church congregation. The researcher sought the
permission of those in authority at proposed sites, such as
the pastor or traditional healer, before commencing
observation and participation, and ensured that all persons who were involved in periods of observation were
informed of the nature of the research.
Of particular concern in this study were occasions when
the researchers encountered people who were being
treated within the shrine and prayer camps and presented
with severe and distressing symptoms. Where it was
judged by the principal researcher (who has several years
experience as a clinician in mental health services in the
UK) that the person may benefit from psychiatric treatment, the researchers advised the person and their family
of the availability of medical treatment for such illnesses
and the potential benefits. Assistance was provided to
access health services if this was the wish of the family and
the patient. Where a person was considered to be at imminent risk of a serious deterioration in physical or mental
health due to the methods employed by healers the
researcher informed the local CPN and senior researchers
and medical staff at Kintampo Health Research Centre. In
some cases where people with mental illness were
chained, treatment with psychotropic drugs appeared to
improve the mental health of the patient sufficiently for
the family to release the person.
Results
The limits of family care
Almost all those with mental illness encountered in this
research had been chained, either at home, or within healing centres. The most common form of restraint was metal
Source
n=
n=
10
9
3
6
4
6
25
31
4
3
4
TOTAL
38
TOTAL
67
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n=
Church members
Muslims (men)
Muslims (women)
Young people
Cannabis smokers
Parents
Registered mental nurses
8
7
7
8
5
7
5
TOTAL
47
When the illness first occurred I took him to Ankaful [psychiatric hospital] for his brain to be examined, [...] They didn't
explain anything, and prescribed some medicine to give him.
They told us that when the medicine was finished we should go
to Sunyani. So when the medicine was finished, we went back
for more. Yet still, the illness was getting worse, so we went to
a prayer camp.
Interview with father of Kwasi, shrine, 18th June 2008
Spiritual perspectives on mental illness reinforce the popularity of the shrines and churches, since, unlike the hospitals, they address factors such as evil spirits, sorcery and
witchcraft, which are commonly seen to have caused mental illness.
With no ambulance service or medical staff available to
provide an escort, families faced a challenging task bringing disturbed and agitated relatives to places of treatment,
particularly if using public transport, for most the only
affordable means. One relative described how her brother
had to be restrained by seven men in order to bring him
to the shrine for treatment. This family paid the police
who used their handcuffs to restrain the man and bring
him to the shrine in a car.
Chaining of patients is generally conducted with the cooperation of the families who bring their relatives to healing centres. Indeed, several family members reported purchasing the shackles used to restrain their relative. At least
four families visited had also resorted to chaining their
mentally ill relative at home. Carers interviewed at the
shrine and churches were generally accepting of the need
to chain their relative if he or she was 'aggressive', 'roaming around', disruptive or using cannabis. Being 'disturbing' (gidigidi), and 'roaming' (kyinkyin), were common
reasons for the use of chains. The father of Kwasi viewed
the use of chains as important to control his son when he
became loud, hyper-talkative and disruptive, behaviour
which we had witnessed on our visits:
He was mostly chained to a tree. He was released whenever he
calmed down. That is how I saw it....When the sickness came,
he made a noise and they chained him to a tree.
Interview with father of Kwasi, shrine, 18th June 2008
Some parents also seemed haunted by a fear of their child
becoming vagrant, a common fate for those with mental
illness who often seemed compelled to wander far from
home. Akua was living in a prayer camp and had had a
severe mental illness for 10 years. She and her mother provide a typical description of this restlessness that could
lead to people with mental illness wandering into the
bush:
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Such behaviour directly contravenes social ideals of personhood, in which taking responsibility for others, such
as parenting children, is valued as the mark of adulthood
[25]. The Ghanaian philosopher, Kwasi Wiredu, claims
that for the Akan, 'a person in the true sense is not just any
human being, but one who has attained the status of a
responsible member of society', that is someone who 'is
able to achieve a reasonable livelihood for himself and
family while making non-trivial contributions to the wellbeing of appropriate members of his extended kinship circles and the wider community' [26]. All of those we met
suffering from chronic mental illness were falling well
outside this ideal since most were unable to work, and
almost all were unmarried and childless. Given this failure
to achieve these markers of adulthood and responsibility,
the status of the mentally ill was in some way analogous
to that of a child.
This loss of social status is captured by the concept of a
'spoiled' human being, which was used by some informants to describe those who had become mentally ill. Akua
told us:
'They say that now I'm spoilt. I'm not a human being anymore.'
Interview with Akua, prayer camp, 8th May 2008
The Twi se, translated here as 'spoilt' is a polysemic word,
used to describe moral corruption, bewitchment or bedevilment, rotten food, something gone bad or wasted. One
of the pastors for example, explained how the devil had
'spoiled' a man through alcohol. A 'spoiled' status, as in
Akua's statement, implies a loss of a person's essential
humanity and carries a moral charge. The implication is
that those with mental illness may be subject to forms of
harsh treatment which would not be permitted to other
categories of person.
Chains as part of treatment
The use of chains and shackles formed a routine part of
treatment in the shrine and churches visited. Every healer
visited during the research, whether a Christian pastor or
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There [at a prayer camp] they beat her severely with a belt,
today you can see her back, all over her back. They said she
should say she is a witch, but she is not a witch, and so they beat
her severely with a belt, she had wounds all over her back.
Extracting a confession was viewed by healers as important since if the person failed to confess their wrongdoing, they could not be healed.
At the time they brought him, it was very difficult. He was very
violent. When it happened like that, he got new strength. So we
had to put him in chains because if you leave him, he could
There are people maybe they did something evil, and the evil
they did brought the problem [madness]. There are people who
after prayers they have to confess before the healing will come.
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rural and urban areas, leading to financial burden, emotional strain and social stigma. This research also reported
how families had struggled to manage difficult and sometimes violent behaviour by people with mental illness
towards family members, such as beatings and setting
fires. Churches and mosques were reported to be important sources of material help [33]. In countries where
social structure and health care has been devastated by
war, government resources for the treatment and care of
those with mental illness are even more scarce. A recent
Channel 4 documentary shown in the UK, for example,
provided graphic coverage of the use of chains within
Sierra Leone's sole psychiatric hospital (staffed by the
country's only psychiatrist), and within the compounds of
traditional healers. In this film, both the psychiatrist and
healers defended the use of chains as necessary to prevent
their patients running away from treatment [34].
As shown in this study, given the lack of state welfare provision in many African countries, responsibility for the
care of those with severe mental illness lies with the family, leading to a significant carer burden [29-33]. A study
in Nigeria showed that caregiver burden was higher where
the relative demonstrated psychotic symptoms and 'uncooperative behaviour' [32]. As in this research, a study in
Ghana of family responses to mental illness found that
the family provided the main source of support in both
Discussion
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MHaPP in Kintampo to promote the human rights of people with mental illness in the district. Initiatives such as
these, which establish a dialogue with local actors, could
begin to address the factors which contribute to the continued use of chaining and other forms of abuse, and
work alongside families and healers to protect and promote the rights, dignity and health of those with mental
illness.
However it should be cautioned that such a moral perspective on rights and responsibilities may also be used to
justify the maltreatment of the mentally ill as this research
has suggested. The morally suspect status of the mentally
ill may be seen to threaten the cohesion and moral integrity of the group, thus they may be excluded from entitlement to the rights otherwise accorded to morally upright
and socialised human beings. Their rights are likely to be
subsumed to the needs of the group thereby sanctioning
the use of whatever means necessary to control behaviour
which threatens this cohesion. As this research shows, to
fail to address the issue of the chaining of the mentally ill
and other practices of restraint, is to ignore the significant
cost for those chained and beaten: socially, physically and
psychologically. Several patients had suffered lasting
physical damage as a result of being chained for long periods, such as muscle wasting and shortening. Many bore
scars on their ankles, evidence of the abrasion caused by
the shackles. Some were resentful of the treatment
received at the hands of their families, or of healers or pastors into whose care they had been entrusted by family
members. In some cases this can lead to a breakdown in
family relationships from which some families never
recover. The ultimate risk surrounding attempts at chaining and restraining those who are agitated or aggressive,
was tragically illustrated during the course of fieldwork. In
May 2008 a young police officer experienced a mental
breakdown whilst in a church in Kintampo, and began to
behave aggressively, smashing objects and shouting. As
yet the facts of the case have not been verified, however it
appears that in the course of attempts to restrain him by
church elders, the man's neck was broken and he died.
Limitations
This study suffers from a number of limitations most of
which are inherent in the anthropological approach with
its focus on 'ethnographies of the particular' [48] and the
use of key informants. Whilst it provides an indepth study
of factors surrounding responses to mental illness within
the communities under study, caution should be exercised in generalising these findings elsewhere since the
sample size is small and particular personal, historical,
social and cultural factors will vary. Ideally a greater
engagement between such qualitative anthropological
studies and quantitative research utilising standardised
instruments along the lines suggested by De Jong and Van
Ommeren for cross-cultural epidemiology [49] could provide a means of counterbalancing the limitations of both
methodologies within international mental health
research. Whilst the long period spent in the field may
have helped to minimise the effect of the researchers during participant observation and interviews to some
degree, the presence of both educated Ghanaian researchers and a white European researcher undoubtedly influenced the responses provided in both positive and
negative ways. For example, the informants may have
been able to say things to a 'stranger' that they could not
say to a member of the community, but equally they may
not have been willing to disclose other facts to 'strangers'.
The use of Twi as the lingua franca may have disadvantaged those for whom it was not their first language, and
the process of translation inevitably leads to some loss or
distortion of meaning. We attempted to minimise this
through transcription first into Twi and through explanation of the Twi words used where these were polysemic
and had no direct translation in English.
Conclusion
There remains a gap between the global discourse on
health (one conducted largely in English, the language of
power), which is echoed within the corridors and conference rooms of ministries of health within Ghana and
other low-income countries, and the conversations and
decisions around health care which take place at community level. This research illustrates some of the challenges
faced by families in supporting relatives with mental illness, and the suffering endured by those who are subjected to chaining, beating and other forms of harsh
treatment within healing centres and family homes. As
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with few material or financial resources to access treatment at more distant health care facilities. They must also
be creative enough to overcome the limitations of a strict
biomedical psychiatry and find ways of working with
local families and healers to improve the care of those
with mental illness and relieve something of the burden
felt by many carers.
Legislation to protect the human rights of people with
mental illness is undoubtedly a vital tool to regulate
abuses within both government and private treatment
facilities. However such legislation is likely to prove
harder to implement within small rural communities
which are distant from the reach of the state, and will be
beyond the means of many to exploit for their protection.
Ultimately engaging with local actors as they struggle to
live with mental illness and search for a cure, may promise
more in terms of changing responses to mental illness
than creating legal sanctions which are unlikely to provide
immediate benefits in the short term.
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16.
Competing interests
17.
Authors' contributions
UMR conceived of the study, and developed its design.
She participated in all aspects of the research and prepared
the draft of the manuscript. SN completed the interviews
and focus group discussions, participated in fieldwork,
and helped develop the research questions. SN and EA
read the manuscript and provided additional comments.
All authors edited and approved the final manuscript.
18.
19.
20.
21.
Acknowledgements
We gratefully acknowledge the support of Kintampo Health Research Centre in conducting this study, in particular Dr Victor Doku, Dr Seth Owusu
Agyei, and the mental health research team. We also thank Ms Mary
Lamptey, CPN Kintampo. The study was funded by the Economic and Social
Research Council, UK in collaboration with Kintampo Health Research
Centre who provided logistical support.
22.
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